Application For Crematory Facility License Form printable pdf download

STATE OF IDAHO

BUREAU OF OCCUPATIONAL LICENSES

Owyhee Plaza

1109 Main Street, Suite 220

Boise, Idaho 83702-5642

APPLICATION FOR CREMATORY FACILITY LICENSE

___________________________________________(please type or print)__________________________________________

Name of Crematory____________________________________________________________________

Crematory Address____________________________________________________________________

street

city

zip

Crematory Mailing Address______________________________________________________________

street/route/box

city

zip

Daytime phone _(____)____________ Fax _(____)_____________ E-mail_______________________

Owner(s) Name_________________________________________________ License # ______________

(Please attach a photocopy of your current license.)

Funeral Establishment Name _______________________________________License #______________

(Please attach a photocopy of your current license.)

Has a crematory previously existed at this location?

( ) YES

( )NO

If YES, give previous name ________________________________________, License #_____________

and owner name_______________________________________________________________________

(If YES and the license is current, said license must be surrendered and signed by the previous owner.)

Does this application represent a change in location of your crematory?

( )YES

( )NO

(If YES, give name ______________________________________________, License #_____________

and former crematory address____________________________________________________________

I hereby make application for a Crematory license and enclose the required fee of $100.

I hereby certify that the above named crematory meets the licensure requirements as outlined by Idaho

Board of Morticians Laws and Rules and shall be subject to all provisions of those Laws and Rules.

I further certify that I am familiar with all city, county, and state planning and zoning regulations affecting

the facility and location listed above and that I assume all responsibility for their compliance.

I further certify that the information recorded hereon is correct to the best of my knowledge and belief.

__________________________________________

Signature of Owner(s) or Agent(s)

State of Idaho, County of ______________________, ss.

Subscribed and sworn before me this _____ day of ______________, 20 ____.

___________________________________________

(seal)

Notary Public official signature

residing at__________________________________

my commission expires_______________________

(over)

BOL:MOR-CRE - revised 01/00

Application For Crematory Facility License Form

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